Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) - May we leave a message? Yes No Cell Phone #: ( ) - May we leave a message? Yes No Email Address: Race: White Black/African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander Unknown Refuse to Report Ethnicity: Hispanic or Latino Non-Hispanic or Latino Unknown Refuse to Report Marital Status: Primary Language: English Spanish Refuse to Report EMPLOYMENT: Employment Status: Employer s Name: Occupation: Retirement Date: Address: City State Zip Code Phone # INSURANCE INFORMATION: Primary Insurance Company s Name: Name as it Appears on the Card: Cardholder s Date of Birth: Cardholder s Social Security #: / / - - Member ID #: Group Name or #: Secondary Insurance Company s Name: Name as it Appears on the Card: Cardholder s Date of Birth: Cardholder s Social Security #: / / - - Member ID #: EMERGENCY CONTACT: Name: Home Phone #: ( ) - Group Name or #: Relationship: Additional Phone #: ( ) - Patient Signature: Date: / / Reviewed/Revised 03/23/2016, 11/04/2016
PATIENT HEALTH HISTORY: ADULT Your answers on this form will help your healthcare team obtain an accurate history of your medical concerns and conditions. Please do your best to complete all four pages. If you cannot remember specific details or if you have questions/concerns about the information we are requesting, please speak with your healthcare team. Personal Medical History: Please indicate with an X if you have had the following: Condition: X Condition: X Condition: X CARDIOVASCULAR BLOOD CONDITION CANCER Atrial Fibrillation Anemia Blood/ Leukemia Congestive Heart Failure Blood Transfusion Brain Heart Attack Blood Clot Breast High Cholesterol Colon Hypertension EMOTIONAL/BEHAVIORAL Lung Alcoholism Ovarian EYES/EARS Alzheimer s Disease Prostate Blindness Anxiety Cataract Attention Deficit Disorder Glaucoma Bipolar Disorder ENDOCRINOLOGY/RENAL Hay Fever Depression Chronic Renal Failure Hearing Loss Drug Use Diabetes Type 1 Eating Disorder Diabetes Type 2 GASTROINTESTINAL Memory Problems Dialysis Celiac Disease Post-Traumatic Stress Disorder Kidney Disease/Kidney Stone Colitis Schizophrenia Thyroid Disorder Colon Polyps Urinary Tract Infection-frequent Crohn s Disease (Granulomatous) MUSCULOSKELETAL Diverticulitis Arthritis NEUROLOGICAL Gastrointestinal Bleeding Back/Neck Injury Migraine/Headaches GERD (heart burn/reflux) Carpal Tunnel Syndrome Seizure Disorder Hemorrhoid Chronic Pain Stroke Hepatitis Gout Tremor Irritable Bowel Syndrome Osteoporosis Liver Disease OTHERS Pancreatitis RESPIRATORY Autoimmune Disorder Asthma Erectile Dysfunction PREGNANCY COPD (Emphysema) Fibromyalgia Number of pregnancies: Pneumonia HIV Number of live births: Pulmonary Embolism Skin Condition Respiratory Disorder Sleep Apnea Tuberculosis Please List Your Preferred Pharmacy: Location: 1 P a g e
Name of Drug Dose Times Per Day Reason Prescribed By ALLERGIES: Source: (medications, pollens, food, animals, other) Type of Reaction SURGICAL HISTORY: Please indicate with an X in the appropriate box if the following procedure is applicable to you. Surgical Procedure X Year Surgical Procedure: X Year Abdominal Surgery Heart surgery Appendectomy (Appendix) Hernia Repair Back Surgery Hip Surgery Biopsy Hysterectomy Breast Biopsy Knee Surgery Breast Surgery LEEP (Cervix Surgery) Colonoscopy Ovary Removal Coronary Bypass Sigmoidoscopy Coronary Stent Sinus Surgery Cosmetic Surgery Tonsillectomy EGD (Stomach Endoscopy) Tubal Ligation Cataract Gallbladder Removal FAMILY HISTORY: Please indicate with an X if a family member has one of the following conditions: Condition Mother Father Siblings Grandparents Cancer Diabetes Glaucoma Heart Disease High Blood Pressure Mental Illness Stroke 2 P a g e
LIFESTYLE / SOCIAL HISTORY Do you smoke tobacco (circle one)? YES or NO If yes, about how many/day? Do you feel you need to change this habit? YES or NO Do you drink alcohol (circle one)? YES or NO If yes, please answer the following questions: Approximately, how many drinks per week? If 3 or more drinks per week, how many per day? 0-3 3 or more 0-2 2-5 5 or more What is your favored drink type? Beer Wine Liquor Have you ever felt you should cut down on your drinking? YES or NO Have people annoyed you by criticizing your drinking? YES or NO Have you ever felt bad or guilty about your drinking? YES or NO Have you ever taken a drink first thing in the morning to steady your nerves or get rid of a hangover? YES or NO Do you use other substances such as marijuana or other drugs (circle one)? YES or NO If yes, about how many times? Per week Per day Please list substance(s) used: How many days in the last two weeks have you been bothered by the below symptoms? Little Interest, Pleasure in Activities Feeling Down, Depressed, Hopeless Please continue on to the following questions, if you chose an option other than not at all from the questions above. If you have chosen not at all to both questions, you may skip to the next section. How many days in the last two weeks have you been bothered by the below symptoms? Trouble Falling or Staying Asleep Feeling Tired or Little Energy Difficulty Getting Along with Others Thoughts about Hurting Yourself Trouble Concentrating Poor Appetite or Overeating Feeling Bad about Yourself 3 P a g e
Name: Date of Birth: Todays Date: DOMESTIC VIOLENCE SCREENING Have you ever been physically or emotionally abused by a partner? YES NO Have you been physically hurt by someone in the last year? YES NO Within the last year has someone forced you to have sexual activity? YES NO If you have been diagnosed as having Diabetes, please let us know when your last testing was completed below. Name of Test Date Last Performed Place Last Performed If unknown, circle option: Microalbumin Hemoglobin A1C Eye Exam Foot Exam IMMUNIZATIONS: Please check off any vaccinations you have had, please add the approximate date if known. Vaccination: Month /Year: Vaccination: Month /Year: Flu Shot Pneumonia Hepatitis A Shingles Hepatitis B Tetanus HPV Tetanus w/pertussis MMR Varicella (Chicken Pox) Meningitis Have you had any of the following screening tests? Screening test/other test Date Location Result (please circle) Colonoscopy Normal Abnormal Dexa (Bone Density) Scan Normal Abnormal Mammogram Normal Abnormal Pap Smear Normal Abnormal Lipid Panel Normal Abnormal Aortic Aneurysm Normal Abnormal FUTURE PLANNING Do you have an advance directive? YES or NO If yes, does PSMC have a copy of it? YES or NO If no, please provide a copy to PSMC for our records. If you do not have an advance directive, do you wish to receive further information? YES or NO 4 P a g e Reviewed/Revised 11/29/2016, 6/21/2018